The Laryngoscope
C 2013 The American Laryngological,
V
Rhinological and Otological Society, Inc.
Are Prophylactic Antibiotics Useful in the Management
of Facial Fractures?
Lisa M. Morris, MD; Robert M. Kellman, MD
QUESTION
Are Prophylactic Antibiotics Useful in Management
of Facial Fractures?
BACKGROUND
Surgeons operating in the head and neck commonly
treat facial fractures; however, the role of prophylactic
antibiotics remains controversial. Facial fractures vary
in location and severity and can span the range of
wound classifications including clean, clean contaminated, contaminated, and dirty/infected. It is clear that
actively infected facial fractures should be treated with
therapeutic antibiotics; however, there is widespread
variability in the use, type, timing, and duration of prophylactic antibiotic use in practice today. In an era of
increased antibiotic resistance, as well as greater focus
on evidence-based medicine and reducing health care
costs, it is important to review the current evidence for
the role of prophylactic antibiotics in facial fractures.
LITERATURE REVIEW
A literature review was conducted using the search
terms “antibiotics,” “prophylaxis,” “facial,” “zygoma,”
“orbital,” “maxillofacial,” “mandibular,” “frontal sinus,”
and “fracture.” Five studies with the highest level of evidence regarding the questions of efficacy, timing, duration, and antibiotic choice for prophylactic antibiotics for
facial fractures were included in this review. Both mandibular and nonmandibular facial fractures were
included. Definitions regarding the timing of antibiotic
prophylaxis are subsequently described in Figure 1.
The efficacy of prophylactic antibiotic use for facial
fractures is established by the systematic review per-
From the Department of Otolaryngology & Communication Sciences, SUNY Upstate Medical University, Syracuse, New York, U.S.A
Send correspondence to Robert M. Kellman, MD, Department of
Otolaryngology & Communication Sciences, SUNY Upstate Medical University, 750 East Adams, Syracuse, NY, USA 13210-2375. E-mail:
[email protected]
Editor’s Note: This Manuscript was accepted for publication on
July 25, 2013.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
DOI: 10.1002/lary.24364
Laryngoscope 124: June 2014
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formed by Andreasen et al.1 in 2006. Six studies, four
randomized controlled trials (RCT), were included. The
four RCTs demonstrate that prophylactic antibiotics significantly decreased the rate of infection in mandibular
fractures by three-fold. Three of the included studies
analyzed duration of antibiotic use and found no benefit
of postoperative prophylactic antibiotics given longer
than 24 to 48 hours for mandibular fractures. Specific
antibiotics were included in the studies, with cefazolin,
ceftriaxone, and penicillin found to be effective. Only one
study evaluated other facial fractures in addition to the
mandible. It found no infections involving the maxilla,
zygoma, or mandibular condyle region, with or without
antibiotic prophylaxis. Due to the low risk of postoperative infection, prophylactic antibiotics are not indicated
in these fractures.
In further efforts to determine the efficacy of continuing antibiotic prophylaxis postoperatively Miles,
Potter, and Ellis2 performed a prospective RCT of open
mandibular fractures treated with open reduction internal fixation (ORIF). All 181 patients received preoperative and perioperative antibiotics of various regimens.
Patients randomized to the antibiotic group received a
single depot injection of intramuscular penicillin G benzathine at the completion of the surgical repair.
Patients allergic to penicillin received a 5 to 7 day
course of oral clindamycin. Patients randomized to the
second group received no postoperative antibiotics. The
infection rates were 9.8% and 14% for the antibiotic
and no antibiotic groups, respectively. These results
were not found to be statistically significant (P 5 0.399)
with the conclusion that there was no statistical benefit
for the administration of postoperative prophylactic
antibiotics in patients undergoing ORIF of mandibular
fractures.
In 2010, Knepil and Loukota3 further evaluated
antibiotic prophylaxis of nonmandibular facial fractures.
This multi-institutional prospective cohort study evaluated the outcomes of prophylactic antibiotics following
surgical treatment of 134 patients with zygomatic fractures. The overall postoperative infection rate was 1.5%,
with infections occurring only after transoral surgical
approaches with antibiotic prophylaxis of cofluampicillin
preoperatively and two doses postoperatively. This study
indicated the fact that the postoperative infection rate of
zygomatic fractures is very low.
Morris and Kellman: Prophylactic Antibiotics in Facial Fractures
Fig. 1. Definitions of prophylactic antibiotic
timing.
Lauder et al.,4 also in 2010, retrospectively evaluated
the timing of antibiotic prophylaxis in nonmandibular
facial fractures with 223 patients divided into four groups:
1) pre- and perioperative; 2) perioperative only; 3) periand postoperative; 4) pre-, peri-, and postoperative. There
was no significant difference of infection rate found among
the four groups (P 5 0.248). More severe injuries were
found in group 4, which suggests that patients with a
high number of fractures and an open fracture pattern
may benefit from maximal (pre-, peri- and postoperative)
prophylactic antibiotics. The study concluded that there is
no increased benefit of antibiotic prophylaxis for nonmandibular facial fractures outside the perioperative timeframe, except possibly in multiple or open fractures.
In 2011, Kyzas5 performed a follow-up systematic
review specifically evaluating the quality of the literature regarding the use of antibiotic prophylaxis in the
treatment of mandibular fractures. Thirty-one studies
were included in the review (9 RCTs and 22 retrospective case series). The literature was found to be of poor
quality and varied data, which was insufficient to perform quantitative synthesis. Overall percentage of postoperative infections ranged from 4.5% to 62% when no
antibiotics were used and 1.9% to 29.4% when antibiotics were used. Forty-two percent of the studies did not
specify which antibiotics were administered. The
remaining studies utilized at least 25 different antibiotics, with penicillins and cephalosporins as the most common antibiotic groups. The review concluded that
current evidence supporting the use of prophylactic antibiotics in the treatment of mandibular factures is limited
and of doubtful quality. Because the RCTs were small,
underpowered, and had many methodological shortcomings, their conclusions are unreliable. The author
warned that the current literature should be interpreted
Laryngoscope 124: June 2014
with great caution and that no standard protocol can be
recommended; however, the literature does show
“scattered signals” to support the superiority of prophylactic antibiotics over no treatment. Kyzas concluded
that a large, multicenter RCT is necessary to better
understand the role of prophylactic antibiotic use in
mandibular fractures.
BEST PRACTICE
Current evidence supports the use of prophylactic
antibiotics in mandibular fractures, probably from the
time of injury until the completion of the perioperative
course, with no additional benefit of postoperative antibiotic prophylaxis. There is insufficient data to evaluate
the efficacy of prophylactic antibiotic use in nonmandibular facial fractures or in isolated fractures of the mandibular condyle. However, there is evidence that
postoperative prophylactic antibiotics are not beneficial.
There is limited data regarding the antibiotic of choice
for prophylaxis. Surgeon discretion remains important
as the quality of current evidence is limited. A large,
multicenter, high-quality RCT is needed to better evaluate the effectiveness, timing, duration, dosage, and antibiotic of choice for antibiotic prophylaxis of facial
fractures.
LEVEL OF EVIDENCE
The body of literature pertaining to antibiotic prophylaxis of facial fractures ranges from 1a,1,5 1b,3 2b.2,4
However, as shown by the Kyzas study, the RCTs were
of limited quality and therefore the literature should be
classified as levels 2a1,5 and 2b2–4 at best, according to
the Oxford classification of levels of evidence.
Morris and Kellman: Prophylactic Antibiotics in Facial Fractures
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BIBLIOGRAPHY
1. Andreasen JO, Jensen SS, Schwartz O, Hillerup Y. A systematic review of
prophylactic antibiotics in the surgical treatment of maxillofacial fractures. J Oral Maxillofac Surg 2006;64:1664–1668.
2. Miles BA, Potter JK, Ellis E 3rd. The efficacy of postoperative antibiotic
regimens in the open treatment of mandibular fractures: a prospective
randomized trial. J Oral Maxillofac Surg 2006;64:576–582.
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3. Knepil GJ, Loukota RA. Outcomes of prophylactic antibiotics following
surgery for zygomatic bone fractures. J Craniomaxillofac Surg 2010;38:
131–133.
4. Lauder A, Jalisi S, Spiegel J, Stram J, Devaiah A. Antibiotic prophylaxis
in the management of complex midface and frontal sinus trauma.
Laryngoscope 2010;120:1940–1945.
5. Kyzas PA. Use of antibiotics in the treatment of mandible fractures: a
systematic review. J Oral Maxillofac Surg 2011;69:1129–1145.
Morris and Kellman: Prophylactic Antibiotics in Facial Fractures